Saving the diabetic foot with special reference to the patient with chronic renal failure.

The chronic renal failure patient with diabetes has a lower limb amputation rate 10 times greater than the diabetic population at large. In studies of causal pathways leading to non-traumatic related lower extremity amputation, foot ulcers preceded approximately 84% of the amputations. Even though foot ulcers are more likely to develop in patients with diabetic nephropathy, they are no less likely to heal than are those in diabetic patients with normal renal function. Consequently, attempts to save the diabetic foot even in this high-risk population are justified. The pathogenesis of foot ulceration in the chronic renal failure patient with diabetes is primarily due to peripheral neuropathy. Loss of protective sensation due to sensory neuropathy combined with motor and autonomic neuropathy and macrovascular compromise result in increased risk for foot complications. Evaluation of the foot includes a selective history and a focused examination of skin integrity, presence of sensory neuropathy or vascular insufficiency, and biomechanical and footwear inspection. Effective treatment of diabetic foot complications include appropriate antibiotics (when indicated), meticulous wound care, off-loading, vascular surgery (when indicated), and selective/elective or prophylactic nonvascular surgery. Failure to heal an ulcer can often be traced to common pitfalls, which include: A "cavalier" attitude. W.N.L. exam (We Never Looked). Inadequate off-loading. Failure to establish depth of ulcer and miss "probe to bone." Non-healing means unrelieved pressure and/or no blood. Failure to correct edema. The multidisciplinary diabetic foot clinic model provides an ideal setting for early intervention, treatment, and assistance with preventive strategies.

A comparison of diabetic foot ulcer patients managed in VHA and non-VHA settings.

OBJECTIVE: To compare patients with diabetes and new onset foot ulcers treated in Veterans Health Administration (VHA) and non-VHA settings. METHODS: The treatment of patients with new onset diabetic foot ulcers was prospectively monitored in three VHA and three non-VHA hospitals and outpatient settings until ulcer healing, amputation, or death. RESULTS: Of the 302 individuals enrolled in this study, 47% were veterans receiving VHA care. There were no significant differences between veterans and nonveterans in baseline wound classification, diabetes severity, or comorbid conditions. Veterans received significantly fewer sharp debridements, total contact casts, and custom inserts than their nonveteran counterparts, and they had significantly more x-rays, local saline irrigations, IV antibiotics, and prescriptions for bed rest. The percentage of amputations was higher in veterans but did not achieve statistical significance. CONCLUSIONS: Many commonly held stereotypes of veteran men were not found. Veterans and nonveterans with foot ulcers were similar in terms of health and foot history, diabetes severity, and comorbid conditions. There was considerable variation in treatment of diabetic foot ulcers between VHA and non-VHA care. Yet this variation did not result in statistically significant differences in ulcer outcomes.

Outpatient parenteral anti-infective therapy for skin and soft-tissue infections.

Skin and soft tissue infections (SSIs) are one of the many infectious diseases that can be treated by outpatient parenteral anti-infective therapy (OPAT). Determining whether a patient with SSIs is treated topically, orally, or parenterally depends on the severity of infection and host factors. The decision to hospitalize, initiate, or transition to OPAT with SSIs depends on the medical assessment and consideration of available resources for OPAT. Anti-infective selection depends on the clinical presentation, likely organisms, pharmacodynamics, pharmacokinetics, and drug stability.

Negotiating with administration--or how to get paid for doing hospital epidemiology.

Many hospital administrators acknowledge the value of a hospital epidemiologist. However, many hospital epidemiologists are not being paid for their work. To eliminate this inequity, hospital epidemiologists must negotiate contractual relationships successfully with their hospitals or healthcare systems. This article reviews an approach to rectifying this problem that is based on practical experience.

Treatment of antibiotic-associated Clostridium difficile colitis with oral vancomycin: comparison of two dosage regimens.

PURPOSE: High-dose (500 mg orally four times daily) vancomycin is considered by many investigators to be the most effective treatment for antibiotic-associated Clostridium difficile colitis. However, a lower dosage of 125 or 150 mg given three or four times a day has become popular, has been shown to be effective, and is less expensive than the high-dose regimen. We therefore decided to compare two vancomycin dosage regimens in a randomized trial. PATIENTS AND METHODS: The study involved 46 hospitalized patients with serious underlying diseases complicated by C. difficile diarrhea or colitis. Patients were assigned (according to a table of random numbers) to treatment with either 125 or 500 mg of vancomycin orally four times daily for an average of 10 days. RESULTS: No significant differences in measurable responses to the two regimens were noted. There were no treatment failures. The mean duration of diarrhea after initiation of therapy was about four days, and almost all patients had no diarrhea after one week. The organism continued to be demonstrated in the stools of about 50 percent of patients for the first few weeks after completion of therapy, and nine (20 percent) patients developed a recurrence of their diarrheal illness. Vancomycin was well tolerated by all patients. CONCLUSION: Since the dose of 125 mg appeared to be as effective as the 500-mg dose, which is more expensive, the 125-mg dose is preferred when vancomycin is used in treatment of this disease, unless the patient is critically ill.

Effects of topical clindamycin on intestinal microflora in patients with acne.

Thirty-two patients with acne completed a randomized, double-blind study using topical 1% clindamycin phosphate or its vehicle applied twice daily for 8 weeks for a study of its effects on the intestinal microflora. Two clindamycin patients and one vehicle patient had Clostridium difficile in stools prior to therapy. Of the remaining twenty-nine patients, four of nineteen patients who used clindamycin and none of ten patients who used vehicle had C. difficile detected during treatment; the difference was not statistically significant. There was no diarrhea in the clindamycin group, even though clostridial cytotoxin was found transiently in two patients. Self-limited diarrhea occurred in one vehicle-treated patient, whose stool culture was negative but whose stool specimen showed a positive reaction for C. difficile cytotoxin. With the use of a bioassay, clindamycin was not detected in urine or stool of any patient. No significant changes in Bacteroides fragilis counts in stools were observed in either group.

Treatment of antibiotic-associated colitis with vancomycin.

Sixty-five patients were treated with oral vancomycin for Clostridium difficile colitis associated with treatment of infection by antibiotics. Colitis was confirmed by endoscopy in patients with diarrhoea and positive tests on diarrhoeal stools for Cl. difficile and/or its cytotoxin or, if endoscopy could not be performed, by the presence of fever and peripheral or faecal leucocytosis. Vancomycin dosage ranged from 125 to 500 mg four times daily for an average of about ten days. The mean duration of diarrhoea after starting therapy was four days; abdominal pain and fever usually resolved in two or three days. Post-treatment carriage of Cl. difficile was common. Eighteen per cent of patients developed a recurrence of colitis after treatment was discontinued, but responded to treatment with oral vancomycin, metronidazole, or bacitracin. After comparison of our results with those reported by others we concluded that vancomycin remains the treatment of choice for patients who are acutely and severely ill with Cl. difficile.

Effect of therapy with latamoxef (moxalactam) on carriage of Clostridium difficile.

Twenty-seven patients receiving latamoxef (moxalactam) as a single antimicrobial agent were studied prospectively for Clostridium difficile carriage and development of diarrhoea or colitis. Stools were available prior to therapy from only seven patients, one of whom (14.3%) was an asymptomatic carrier. None of twelve patients studied during therapy were carriers. Seven of 27 patients (25.9%) were colonized with Cl. difficile after completion of latamoxef therapy, and three patients had cytotoxin positive stools. Two patients with cytotoxin grew Cl difficile from stools and one patient was culture negative. Only one patient, who had both culture and cytotoxin positive stools, had profuse diarrhoea. Cl. difficile clinical isolates were only moderately susceptible to latamoxef in vitro. Hamsters given moxalactam developed caecitis. Patients receiving latamoxef, or third generation cephalosporins, may be at increased risk of development of Cl. difficile associated diarrhoea and should be followed closely for this complication, especially after therapy has been discontinued.